Hepatitis C (cont.)

Mary D. Nettleman, MD, MS, MACP

Mary D. Nettleman, MD, MS, MACP is the Chair of the Department of Medicine at Michigan State University. She is a graduate of Vanderbilt Medical School, and completed her residency in Internal Medicine and a fellowship in Infectious Diseases at Indiana University.

Jay W. Marks, MD

Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.

What is the role of a liver biopsy in the management of chronic hepatitis C?

Blood tests can tell the clinician whether HCV is present but cannot tell the level of liver damage that has occurred. Liver biopsy allows the clinician to determine how much inflammation and scarring is present by examining a small sample of liver tissue. Liver biopsy gives information useful in the decision to initiate therapy. Significant liver damage is a risk factor for other conditions such as hepatocellular carcinoma and esophageal varices. Liver biopsy may be recommended when the clinician is uncertain about whether to begin treatment or wishes to monitor the response within the liver to therapy.

It is possible to measure liver stiffness with transient elastography, a non-invasive test. Stiffer livers mean that advanced liver fibrosis may be present. However such tests do not completely replace the need for liver biopsy in routine clinical practice.

Several batteries of blood tests also have been found to be useful in diagnosing cirrhosis; however, like transient elastography, these tests have not completely replaced the need for liver biopsy.

What is the treatment for hepatitis C infection?

Hepatitis C does not always require treatment. There are six genotypes of hepatitis C and they may respond differently to treatment. Careful screening is necessary before starting the treatment to determine the most appropriate approach for the patient.

Combination antiviral therapy with interferon injection and oral ribavirin has been the mainstay of hepatitis C treatment. Unfortunately, interferon is not widely available globally, it is not always well tolerated, some virus genotypes respond better to interferon than others, and many people who take interferon do not finish their treatment. This means that while hepatitis C is generally considered to be a curable disease, for many people this is not a reality.

Scientific advances have led to the development of new antiviral drugs for hepatitis C, which may be more effective and better tolerated than existing therapies. Two of these newer therapeutic agents, telaprevir (Incivek - this drug was withdrawn from the market by the manufacturer in August 2014) and
boceprevir (Victrelis), have recently been licensed in some countries where they are used in addition to interferon and ribavirin. Much needs to be done to ensure that these advances lead to greater access and treatment globally.

The most recently approved oral therapeutic agents for the treatment of hepatitis C are
sofosbuvir (Sovaldi) and
simeprevir (Olysio). These can be used in combination with ribavirin and interferon, but with simeprevir it is possible to eliminate the interferon. The effectiveness of treatment with these combinations of agents is extremely high (greater than 90%), and it now is possible to use treatment that is all oral.